Neuro Physio - Repat Visit Lecture Flashcards

Week 7 – Neuro Physio Chris Bell Physio – Repat Visit Lecture SRU Team

  • Medical Staff (RMOs, Registrars, Consultants), Nursing staff, allied health (EP, PT, SPT, POD, SP, Neuropsych, Dieticians)

Causes of SCI

  • Traumatic vs non-traumatic (cancer on spine, abscesses, falls)
  • Risk-taking young males
  • Speeding, drunk driving not as major issue due to better airbag tech etc.

Management

  • Conservative (non-operative, pin management)
  • Surgical (ORIF - Open Reduction Internal Fixation)
  • Increasing age of SCI onset
  • >50% injuries are incomplete
  • Increased incidence of non-traumatic (older population)

ASIA Classification

  • ASIA A - complete motor and sensory loss including S4-5 segments
  • ASIA B - no motor function, some sensation preserved in S4-5 segments
  • ASIA C - motor in S4-5 segments is preserved or sensory in S4-5 and motor function in more than 3 levels below the injury level.
  • ASIA D - Half or more of the key muscles below the level are grade 3-5
  • ASIA E - normal motor and sensory
  • Zone of partial preservation

Terminology

Manifestations of SCI

  • Motor and sensory loss
  • Pain
    • Mechanical / operational
    • 2° muscle imbalances
    • Neurogenic
  • Bladder, bowel, sexual dysfunction
  • Skin breakdown (pressure injuries)
  • Respiratory issues
  • Personal and social
  • Changes in tone and /or spasms
    • Spinal shock (flaccid tone)
    • UMN (increased tone) vs LMN lesion (More flaccid)

Management

  • Physiotherapy
  • Medical
  • HO - Heterotopic ossification
  • Be aware of risk and monitor

Autonomic Dysreflexia

  • Sympathetic nervous system controls flight/fright (↑BP, ↑RR, ↑HR, vasodilation)
  • Lesions above T6, SNS cut off from cortical control
  • Triggers - bladder distension, constipation, pressure areas, trauma, SLR
  • Signs
    • Sweating usually above the level of the lesion
    • Flushing of skin above the level of the lesion
    • Pounding headache
  • Treatment - remove cause, sit up, medical help
  • IF UNTREATED CAN BE LIFE THREATENING

Clinical Syndromes

  • Brown-Sequard
  • Central Cord
  • Anterior/ posterior cord
  • Cauda Equina

Physiotherapy Management

  • Respiratory
  • Flexibility and joint ROM
  • Pain Management
  • Strength
  • Postural Control
  • Bed Mobility
  • Transfers
  • Gait training
  • Hydrotherapy
  • Swimming

Goal Setting

  • Goals meaningful to the patient
  • Short term goals vs long term goals
  • Understand implication of neurological level
  • Recovery vs compensation

Predictors of Recovery

  • Teaching compensations

Incomplete Lesions

  • Apply all previous principles
  • Predict, identify, and facilitate the return of function
  • Skill transition as function improves
  • Lite gait, BWS gait training, treadmill, hydrotherapy, gym ball, and FES are just some of the Rx options

Aims of Physiotherapy

Additional Resources

  • Want to learn more?
    • Management of Spinal Cord Injuries: A Guide for physiotherapists, Harvey L, 2008, Elsevier Ltd
    • Elearnsci.org
    • Scipt.org
    • Physiotherapyexercises.com
    • Scireproject.com

Readings

  1. Spinal Cord Injury (SCI) – Pathophysiology & Rehabilitation (Ennon, 2018; Patek & Stewart, 2020)
  • Understanding Spinal Cord Injury
  • SCI occurs when the spinal cord is damaged due to trauma (e.g., car accidents, falls, sports injuries) or disease (e.g., tumors, infections).
  • The severity of the injury depends on the extent of damage to the nerves, which affects motor and sensory function below the injury site.
  • SCI is classified into:
    • Complete SCI: Total loss of motor and sensory function below the level of injury.
    • Incomplete SCI: Partial preservation of function, meaning some signals are still transmitted.
  • The injury triggers two phases:
    1. Primary Injury – The initial trauma that directly damages the spinal cord.
    2. Secondary Injury – A cascade of biochemical and inflammatory reactions that worsen the damage over hours to days. This phase includes swelling, loss of blood supply, and release of harmful substances that kill nerve cells.
  • Management & Rehabilitation
    • Early stabilization: Spinal immobilization is crucial to prevent further damage. In cases of instability, surgery (spinal decompression and fusion) may be required.
    • Rehabilitation goals: Therapy focuses on maximizing mobility, independence, and function. Exercises include strength training, stretching to prevent contractures, and functional training (like transferring from a wheelchair to a bed).
    • Complications: SCI patients often experience secondary issues such as pressure ulcers (due to immobility), autonomic dysreflexia (a life-threatening rise in blood pressure), and bladder/bowel dysfunction. Managing these complications is a core part of long-term care.
  1. Respiratory Issues & Management in SCI (Ennon, 2018; Bach et al., 2020)
  • Why Respiratory Function is Affected in SCI
    • Breathing relies on several muscles, including the diaphragm (controlled by the phrenic nerve, C3-C5), intercostal muscles (T1-T11), and abdominal muscles (T6-L1).
    • When the spinal cord is damaged, these muscles can weaken or become paralyzed, leading to:
      • Reduced lung volume → Less effective breathing.
      • Inability to clear secretions → Increased risk of infections like pneumonia.
      • Dependence on ventilators (especially in high cervical injuries).
  • Respiratory Management Strategies
    • Mechanical ventilation: Needed in severe cases (C1-C4 injuries).
    • Non-invasive ventilation (NIV): Helps patients with weakened breathing but who can still manage some effort.
    • Secretion management: SCI patients struggle with coughing, so techniques like assisted coughing, suctioning, and chest physiotherapy help clear mucus.
    • Diaphragm pacing: A device that stimulates the diaphragm to improve breathing in some cases.
  1. Acute Management of SCI (Shank et al., 2019)
  • Key Principles in Acute SCI Care
    • Immobilization: Prevents further damage in the early stages.
    • Blood pressure control: Maintaining adequate spinal cord perfusion (mean arterial pressure >85 mmHg) helps reduce further damage.
    • Steroid use (Methylprednisolone): Previously used to reduce inflammation, but its effectiveness is now debated due to potential side effects (like infections and GI bleeding).
    • Early surgical intervention: Studies suggest that decompressing the spinal cord within 24 hours of injury improves recovery.
  • Emerging Therapies
    • Stem cell therapy: Research is exploring whether stem cells can regenerate damaged nerve tissue.
    • Neuroprotective agents: Drugs that aim to minimize secondary damage and promote nerve healing.
      Muscle Function Grading
  • 0 = total paralysis
  • 1 = palpable or visible contraction
  • 2 = active movement, full range of motion (ROM) with gravity eliminated
  • 3 = active movement, full ROM against gravity
  • 4 = active movement, full ROM against gravity and moderate resistance in a
    muscle specific position
  • 5 = (normal) active movement, full ROM against gravity and full resistance in a
    functional muscle position expected from an otherwise unimpaired person
  • 5* (normal) active movement, full ROM against gravity and sufficient resistance to
    be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present
  • NT=not testable (i.e. due to immobilization, severe pain such that the patient
    cannot be graded, amputation of limb, or contracture of >50% of the normal ROM)
    Sensory Grading
  • 0 = Absent
  • 1 = Altered, either decreased/impaired sensation or hypersensitivity
  • 2 = Normal
  • NT= Not testable

When to Test Non-Key Muscles:
In a patient with an apparent AIS B classification, non-key muscle functions
more than 3 levels below the motor level on each side should be tested to
most accurately classify the injury (differentiate between AIS B and C).

Movement Root level

  • Shoulder: Flexion, extension, abduction, adduction, internal
    and external rotation C5
  • Elbow: Supination C6
  • Elbow: Pronation C7
  • Wrist: Flexion C8
  • Finger: Flexion at proximal joint, extension. T1
  • Thumb: Flexion, extension and abduction in plane of thumb L2
  • Finger: Flexion at MCP joint L3
  • Thumb: Opposition, adduction and abduction perpendicular
    to palm L4
  • Finger: Abduction of the index finger L5
    Hip: Adduction
  • Hip: External rotation S1
  • Hip: Extension, abduction, internal rotation
  • Knee: Flexion
  • Ankle: Inversion and eversion
  • Toe: MP and IP extension
  • Hallux and Toe: DIP and PIP flexion and abduction
  • Hallux: Adduction
    ASIA Impairment Scale (AIS)
    A = Complete. No sensory or motor function is preserved
    in the sacral segments S4-5.
    B = Sensory Incomplete. Sensory but not motor function
    is preserved below the neurological level and includes the
    sacral segments S4-5 (light touch or pin prick at S4-5 or
    deep anal pressure) AND no motor function is preserved
    more than three levels below the motor level on either
    side of the body.
    C = Motor Incomplete. Motor function is preserved at the
    most caudal sacral segments for voluntary anal contraction
    (VAC) OR the patient meets the criteria for sensory
    incomplete status (sensory function preserved at the most
    caudal sacral segments (S4-S5) by LT, PP or DAP), and
    has some sparing of motor function more than three levels
    below the ipsilateral motor level on either side of the body.
    (This includes key or non-key muscle functions to determine
    motor incomplete status.) For AIS C - less than half of key
    muscle functions below the single NLI have a muscle
    grade ≥ 3.
    D = Motor Incomplete. Motor incomplete status as defined
    above, with at least half (half or more) of key muscle functions
    below the single NLI having a muscle grade ≥ 3.
    E = Normal. If sensation and motor function as tested with
    the ISNCSCI are graded as normal in all segments, and the
    patient had prior deficits, then the AIS grade is E. Someone
    without an initial SCI does not receive an AIS grade.
    Using ND: To document the sensory, motor and NLI levels,
    the ASIA Impairment Scale grade, and/or the zone of partial
    preservation (ZPP) when they are unable to be determined
    based on the examination results.
    Steps In Classification
    The following order is recommended for determining the
    classification of individuals with SCI
  1. Determine sensory levels for right and left sides.
    The sensory level is the most caudal, intact dermatome
    for both pin prick and light touch sensation.
  2. Determine motor levels for right and left sides.
    Defined by the lowest key muscle function that has a
    grade of at least 3 (on supine testing), providing the key
    muscle functions represented by segments above that
    level are judged to be intact (graded as a 5).
    Note: in regions where there is no myotome to test, the
    motor level is presumed to be the same as the sensory level
    if testable motor function above that level is also normal
  3. Determine the neurological level of injury (NL)
    This refers to the most caudal segment of the cord with
    intact sensation and antigravity (3 or more) muscle function
    strength, provided that there is normal (intact) sensory and
    motor function rostrally respectively.
    The NL is the most cephalad of the sensory and motor levels
    determined in steps 1 and 2.
  4. Determine whether the injury is Complete or Incomplete.
    (ie. absence or presence of sacral sparing)
    voluntary anal contraction-No AND al S4-5 sensory
    scores-0
    AND deep anal pressure-No, then injury is Complete.
    Otherwise, injury is Incomplete.
  5. Determine ASIA Impairment Scale (AIS) Grade:
    Is injury Complete? If YES, AIS-A and can record
    ZPP (lowest dermatome or myotome
    on each side with some preservation
    Is injury Motor Complete?
    IF YES, AIS-B
    (No voluntary anal contraction OR
    motor function more than three levels
    below the motor level on a given side.
    the patient has sensory incomplete
    dassification)
    Are at least half (half or more) of the key muscles below the
    neurological level of injury graded 3 or better?
    AIS-C
    AIS=D
    If sensation and motor function is normal in all segments,
    AIS=E
    Note: AIS E is used in follow-up testing when an individual
    with a documented SCI has recovered normal function. If
    at initial testing no deficits are found, the individual is
    eurologically intact the ASIA Impairment Scale does
    not apply

Vertebrae numbers

  • Cervical division.
  • Thoracic division.
  • Lumbar division.
  • Sacral division.

Functions

  • Breathing (C1-4) and
    head and neck movement (C2)
  • Heart rate (C4-6)
    and shoulder movement (C5)
  • Wrist and elbow movement (C6-7)
  • Hand and finger
    movement (C7-T1)
  • Sympathetic tone (T1-12)
    (including temperature regulation)
    and trunk stability (T2-12)
  • Ejaculation (T11-L2)
  • and hip motion (L2)
  • Knee extension (L3)
  • Foot motion (L4-S1)
    and knee flexion (L5)
  • Penile erection (S2-S4)
    and bowel and bladder activity (S2-S3)
  • Ascending tract
  • Posterior column
    Fasciculus gracilis
    Descending tract (proprioception, deep Fasciculus cuneatus
    touch, vibration)
  • Dorsal spinocerebellar
    (reflex, proprioception)
  • Lateral corticospinal
    (voluntary movement)
  • Rubrospinal tract
  • Lateral spinothalamic
    (pain, temperature)
    Ventral spinocerebellar
    (reflex, proprioception)
    Vestibulospinal tract
    Ventral corticospinal
    (voluntary movement)
    Ventral spinothalamic
    (light touch, pressure)